Coda Change

Sonowars continues to find new ways to make Ultrasound teaching exciting, inspirational and most importantly informative. The team of James Rippey, Matt Dawson, Mike Mallin and Andrian Goudie are back with an all-star supporting cast. Keep an eye out for the light sabre, simulating ultrasound guided venous canulation as well as the mechanical bull ultrasound challenge. Things are bound to get a little crazy when these guys get fired up.

The host response to injury is inflammation. The inflammatory response may have been naturally selected over millions of years of evolution to give the injured tissue the best chance of healing and recovering. On the other hand, over the last 50 years animal models of traumatic brain injury (TBI) suggest that fever, occurring as part of the inflammatory response, may be harmful to neuronal recovery. Some observational clinical studies support this. However we lack high quality clinical trials.At present clinicians commonly use drugs and physical cooling techniques to suppress fever after TBI and stroke. These approaches have costs and can be resource intensive, as well as be associated with side-effects. We will share with you some of the results from our program in this area. We will discuss ... What is normothermia? How effective are the interventions we use? What temperature do/should we target? What do we achieve? Surely we need a reliable answer to the question of whether the strict maintenance of normothermia (36-37°C) reduces disability and death after TBI? References1.Saxena M, Andrews PJ, Cheng A, Deol K, Hammond N. Modest cooling therapies (35ºC to 37.5ºC) for traumatic brain injury. Cochrane Database of Systematic Reviews 2014.2.Saxena M, Young P, Pilcher D, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med 2015:1-10.3.Young P, Saxena MK, Beasley CRW, et al. Early peak temperature and mortality in critically ill patients with or without infection. Intensive Care Med 2011;38:437-44.4.Saxena MK, Taylor CB, Hammond NE, et al. Temperature management in patients with acute neurological lesions: an Australian and New Zealand point prevalence study. Crit Care Reusc 2013;15:110-8.5.Saxena MK, Taylor C, Hammond N, et al. A Multi-Centre Audit of Temperature Patterns After Traumatic Brain Injury. . Crit Care Reusc 2015 (June);17:129-34.

Making Transitions of Care Safe - Pat Croskerry Summary by: Pat Croskerry It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues. To minimize transition failures, the process should be trained and standardized, recognized as a multi-professional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliability, consistency, and efficacy of the transition should be a hallmark of departmental culture. Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them. The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.

The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.

Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission. Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved. In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth's gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.

A pair of outrageously high heels next to a pair of tattered combat boots, set the stage for Ashley’s talk on the stress of PHARM. Ashley draws on lessons learned in combat to support her theory of mental health survival. She emphasizes the importance of critical incident recognition, response and elimination of stigma associated with seeking help.

Bouncing Back from the Beach – Cutting to Air to secure an Emergency Surgical Airway Summary by: Thomas Dolven To handle airways means being prepared to handle them all the way. You need to be prepared for a cannot intubate cannot oxygenate CICO scenario. The common, final end point of airway management in a is the emergency surgical airway, the cricothyroidotomy. So how to prepare?Often, it is not being taught right. This is a rare procedure under high stress and time sensitive. And most importantly, it is a bloody procedure that will be blind. You cannot use your eyes. So it needs a simple technique without fine motor skills, and it must be tactile. Your finger is the perfect tool for this task, and will guide you through it. The video of my personal real world experience is backed by available empirical evidence and lab training. There will never be an RCT, this is the best evidence we will have. So read NAPP4 and the case series article on the scalpel-finger-tube technique. Read these available articles, train, and remember these two key points:1) There will be blood. But that’s OK, because.2) Your finger can see.

Tox-Dogmalysis is a talk about evidence in Toxicology. It's been said that 50% of what we learn is incorrect; we just don't know which 50%. As the complexity of medicine increases, it is of the utmost importance for clinicians to be skeptical of old data and new data alike. Many in the FOAM community have made huge strides in busting myths that have persisted over time. However, sometimes we may declare myths busted too prematurely based on incomplete or misunderstood data. This talk will explore three topics in toxicology for which the perceived myths may actually be true, or at least not completely busted.

Fluids in Critical Care: Time to SPLIT With Normal Saline? Summary by: Paul Young Intravenous fluid therapy is a ubiquitous treatment for critically ill patients and has been used in clinical practice for over 175 years. Despite this long history, the majority of intravenous fluids have not been subjected to the same level of scrutiny as other drugs. That said, large-scale fluid trials evaluating albumin and starch solutions compared to 0.9% saline have been conducted and their results have changed clinical practice around the world so that crystalloid fluid therapy is now predominant in many parts of the world. While 0.9% saline is the world’s most commonly prescribed crystalloid fluid, increasingly clinicians are turning to buffered or balanced crystalloid solutions as an alternative to 0.9% saline. This practice change from 0.9% saline towards balanced crystalloids is not based on high quality evidence but is supported by observational data suggesting that saline may be associated with an increased risk of renal toxicity and mortality compared to buffered crystalloids. This talk gives an overview of the data comparing the comparative effectiveness of 0.9% saline and buffered crystalloids, provides an overview of the historical context of intravenous fluid therapy (and proctoclysis), and describes the design of the Saline vs. Plasma-Lyte 148® for Intravenous fluid Therapy (SPLIT) trial which has now been completed and was recently published in the Journal of the American Medical Association. External Links• [The Bottom line] SPLIT trial reviewed• [article] Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial• [editorial] Editorial accompanying paper• [videocast] Presentation of SPLIT trial at ESICM by Dr Paul Young• [Further reading] Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults• [St Emlyn's] SPLIT trial published. Saline or Plasmalyte on the ICU?

Mark Wilson hosts an all-star cast!Summary By: Mark Wilson Traumatic brain injury (TBI) is a hugely important topic in critical care. It is a major cause of morbidity and mortality throughout the world with hospital presentations totaling over 2million in the US, 1 million in the UK and 700,000 in Australia each year. Not only do they represent a huge proportion of injuries, but they are a unique in their potential to fundamentally change “who a person is”. As critical care and trauma practitioners there are many aspects of management that can change outcomes for patients in the short and long term. Dr Mark Wilson (@MarkHWilson) is a neurosurgeon and doctor for the Air Ambulance in the UK. In this session from SMACC Chicago entitled “It’s a Knockout”, he expertly leads a discussion which holds a magnifying glass to the current practice guidelines for managing TBI as taught in ATLS. On the discussion panel is a star-studded international cast including: Pierre Janin, Andrew Dixon (@DrAndrewDixon), Karim Brohi (@karimbrohi), Karel Harbig (@karelharbig), Deb Stein, Michael McGonigal, Bill Knight, John Hinds and Ralph the Janitor (who looks remarkably like Cliff Reid @cliffreid). In this discussion forum, international specialists from the fields of neurosurgery, intensive care, trauma surgery, emergency medicine and radiology engage in a discussion of the step-by-step management of a real case of a patient with a head injury. This discussion highlights the many management controversies including how to manage the c-spine, whether or not to oxygenate, whether or not to intubate, when to extubate, if and how to sedate the patient, when to CT and how to monitor the head injured patient. In typical SMACC style this discussion demonstrates the approach to the management of a patient from different vantage points and demonstrates why it is so difficult to come to a consensus of the approach to this type of injury. Panelists delve into the features of TBI that you won’t find in textbooks including impact brain apnoea, multi-compartment syndrome and more. Watch out for the a segue into the Good Sam App, a smartphone app which alerts registered medically trained personnel to nearby emergencies to minimize downtime when medical emergencies occur. This forum has everything you have come to love and expect from SMACC including international experts, heated debates, controversial #hashtags, guest speakers and more!